Alberta Home Visitation Network Association

9321 Jasper Avenue

Edmonton, AB T5H 3T7

Phone: 780 429-4787 Fax: 780 429-4784

Email:

Website:

2012Home Visitation Participant Demographic Profile

Please feel free contact us if you have any questions or need assistance!

Agency Name:

Contact name and number:

Some of your programs may be receiving CFSA Code 355 (Home Visitation) funding. This is indicated below as “355”, or “Non 355” for programs without this type of funding.

355 Funding?Name of agency program represented on next page:

(optionally attach list, if preferred)

CFSA Region:

1 - Southwest Alberta 2 - Southeast Alberta 3 - Calgary and Area 4 - Central Alberta 5 - East Central Alberta 6 - Edmonton and Area 7 - North Central Alberta 8 - Northwest Alberta 9 - Northeast Alberta 10 - Metis Settlements

The following page lists demographic statistics AHVNA is collecting for the 2010-2011 year. The data applies to the same fiscal year is normally used in your reports (Jan-Dec or April-March). The information you provide will be used only in aggregate form by AHVNA.When filling out these demographic statistics, you may relay on whatever methods you’ve normally used to gather data for any regular report. Some data may be missing as families have the right to not answer any questions.

Helpful resources:

The following documents are also available from AHVNA’s website at

- Tipsheet for programs using the HOMES database.

- Spreadsheet calculator (requires Microsoft Excel and manual data entry)

- Alberta Children and Youth Services’ ECD-FASD Activities Report – Some numbers are also found on this report. They’re marked with “” (can use) or “o” (could use IFevery caregiver/child/individual in home in all families are included on the report).

Definitions for profile descriptions:

Individual – Anyone in the home, regardless of direct service involvement or role (child, boyfriend, grandmother, etc)

Caregiver – A parent or anyone of similar role caring for child in home.

Primary Caregiver – One per family. This will usually be the mother.

Completed demographic profiles may be mailed, faxed, or emailed to:

Alberta Home Visitation Network Association

9321 Jasper Avenue

Edmonton, AB T5H 3T7

Phone: 780 429-4787 Fax: 780 429-4784

Email: , Website:

Please feel free to contact us if you have any questions or need assistance!
Code 355Other
Total Families: 
Family marital status:
Single Moms (if avail.)
Single Dads (if avail.)
Total Single Parents
Co-parenting
(married, common law, partner, etc)
Preferred official language spoken in home: (one language per family)
English
Other:
Other:
Other:
Not tracked
(optionally attach list, if preferred)
Families served with the
use of an interpreter.
Families not served due
to language barrier.
Household annual income:
1 - 9,999
10,000 - 19,999
20,000 - 29,999
30,000 - 39,999
40,000 - 49,999
50,000 - 59,999
60,000 - 69,999
70,000+ / Primary caregiver age:
(one pri. caregiver per family) Code 355Other
13 - 17 yrs
18 - 25 yrs
26 - 35 yrs
36 - 45 yrs
46 - 55 yrs
56 - 65 yrs
66+ yrs
Education level of primary caregiver:
(one primary caregiver per family)
Under grade 12
High school
Some or completed
post-secondary
Other factors:
(families may relate to multiple factors)
Parenting alone
Social isolation
Alcohol/drug use
Fam. violence issues
Mentalhealth diag.,
depression, or cognitive
challenges (childcare capacity)
Parent with physical
challenges (childcare capacity)
Not tracked
Ages of all children in home:
Code355 Other
0 - 3 yrs (if available)
4 - 6 yrs (if available)
0 - 6 yrs (total ) 
7 - 12 yrs o
13 - 17 yrs o
Total children: ( total )
Please Note: Home Visitation targets children who are 0to5 years of age or the 6th birthday. / Code355 Other
Total Individuals: o
(everyone in home, including all children)
Individual cultural backgrounds:
Aboriginal o
New Canadian o
(arrival within last 3 years)
Indiv. family caregivers o
involved in parenting role
(can include partner who is away much of the time)
Comments:

Families have the right to not answer any questions. Your program or agency might also not track some details. The “Not Tracked” boxesare used to provide a count of families/individuals for which a detail is not available (i.e. other factors, language). For categories without a “Not Tracked” box, use the comments box to indicate untracked details.

(Rev. Jan 31, 2012)Page 1 of 2